Program Intake Application Form

Would you like to find out more about MND NSW Services before you proceed? 
You can find out about our programs here What We Do and come back to this Form when you are ready to proceed. Or, if you have any questions about this Form or the services we offer, then please do not hesitate to contact us on 1800 777 175.

It should take you about 5 minutes to complete this Intake Form.

How we use the information you provide
The information collected below will be used to ensure we link you to the right support people and programs within our organisation.

All information provided will be held by MND NSW and used by us to provide support, information and to assist us communicate with you. We take your privacy extremely seriously and will work within all legislation and our own policies and procedures to keep your information safe. We will only share information with those people you have authorised. You can, at any time withdraw or change any of the information provided, including making changes or updates to authorised persons, by contacting us ph. 1800 777 175 or 02 8877 0999. You can view our privacy policy at www.mndnsw.asn.au or ask for a copy to be posted to you.

You will always be the first point of contact for decision making. Those authorised to speak on your behalf will only be contacted if you have asked us to do so or if you are unable to speak/communicate on your own behalf for any reason.

What happens after you submit your Form?
You will receive a copy of the details you submitted on the Form by email to the email address you provide on the Form. When we receive the Intake Form we will contact you within 2 working days. We will provide you with an MND NSW Service Agreement which will outline the services to be provided to you, all costs (if any), details of how to terminate services as well as information about your rights and responsibilities in accessing our services. This information is provided to you so you can decide if you wish to proceed.

We will also provide you information about our feedback and complaints processes along with links to our online resources and support group information. 

To proceed please click the Next button below.